6:260-E2 Challenge of Instructional Materials

Please complete this form and return it to the Building Principal who will submit it to the District Complaint Manager. Please print or type.

Title:  __________________________________________

Author:  ______________________________________

Publisher/Producer:  ___________________________________________

Format of Material:  _______________________________________

Subject Area:  _______________________________________

School:  _________________________________

1. Did you review the entire material?           _____Yes           _____No

2. Did you discuss the use of the material in the instructional program with school personnel?           _____Yes           _____No

3. Please state, as precisely as possible, to what in the material you object.



4. In your opinion, what negative effects might result from the use of this material with students?



5. Do you perceive any educational benefit for students resulting in the use of this material?



6. Is there any age group of students for which you would recommend this material?



Complaintant name (please print):  ____________________________________

Telephone:  ________________________________

Complaintant represents:           _____Student      _____Parent/guardian of student      _____Other

Complaintant address:  ______________________________________

Signature of complaintant :  ________________________________


Date Approved: April 10, 2007